What is the authentic underlying reason of childbirth worries in Turkish population?: An observational study

This study aims to determine women’s childbirth worries during antenatal. The research was carried out with 532 pregnant women in the antenatal clinic in Turkey as an observational study. Sociodemographic characteristics and scores of the Oxford Worries about Labor Scale of pregnant women were evaluated quantitatively. In addition, the answers given by the pregnant women to the open-ended question were themed. Although working status and receiving antenatal education reduce the fear of childbirth, birth scenes/stories on TV or social media, birth stories in the pregnant women’s friends/family, being stressed in daily life, and dysmenorrhea increase the worries about childbirth (WaC). In addition, primiparas experience more WaC than multiparas. The reasons for WaC in pregnant women were classified as birth pain, artificial pain, cesarean section/receiving anesthesia, intervention/examination, pandemic, people’s thoughts/experiences, birth process/insufficiency in birth, hospital/staff, fears about the baby, complications/death, and ignorance of the birth process. The results of this study reveal that WaC is a pivotal issue for pregnant women, for which managing the labor process, labor pain and labor fear is important. The stipulation of support for pregnant women is essential to enhance labor outcomes.


Introduction
Being pregnant and giving birth is a peerless experience for each woman.The labor process has multidimensional characteristic features which can be affected by anxiety, apprehension, fears, trauma, exploitation, insufficient social support, economic issues, attitudes toward giving birth, expectations, cultural structures, the quality of the delivery room, and the care given by a midwife or doctor.[3][4][5] Although most women give birth as a spectacular experience, this can also be a frightening experience for some women. [3,6]aC is a common issue, which affects the health indicators of pregnancy, childbirth, and postpartum.[3][4][5][6] WaC also causes women to want a cesarean section in some countries which are even proven safe for maternity care. [3]he research area of WaC is comprehensive and complicated.Many scales are developed to evaluate WaC, and many methods are used to reduce WaC.The prevalence and reasons of WaC are investigated and the level of WaC is measured by using any scales in the literature.[8] The prevalence and reasons of WaC, and the discrepancy of using methods to reduce the WaC prevent making a consensus on the research.For this reason, it is indicated that WaC is necessary to evaluate widely. [3]he aims of our research are (first) to measure the level of WaC by using the Oxford Worries about Labor Scale (OWLS), (second) to evaluate reasons for WaC, (third) to research the predisposing risk factors of WaC, and (fourth) to present openended finds about WaC.

Research sample and design
This study was conducted as an observational study.

The authors have no funding and conflicts of interest to disclose.
All participants gave written informed consent prior to their participation in the study, in accordance with the tenets of the Declaration of Helsinki.
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
The pregnant women (n = 700), who are 18 to 35 years old, have no obstetric complications, are on any gestational week and go to antenatal polyclinic on 15 September to 15 December 2021 were invited by the researchers.The pregnant women who agreed to attend the study received permission from an informed consent form.One hundred twelve of them did not want to attend the study.Eighteen of them (n = 588) wanted to leave the study.Thirty eight of them (n = 570) did not complete the questionnaire.Therefore, we could include 532 pregnant women in the study.
In the first stage, the pregnant women accepted to attend the study (n = 588) filled out the descriptive questionnaire which is constituted by researchers in line with the literature and does not have any validity and reliability.In this stage, 10 pregnant women wanted to leave the study.
In the second stage, the WaC of pregnant (n = 578) were evaluated by using OWLS.
In the third stage, (n = 570) pregnant women's thoughts about WaC and the predisposing factors caused by WaC are evaluated by open-ended questions.38 pregnant women were not included in this stage as they answered incomprehensibly and incompletely.
Five hundred thirty two pregnant women, who continued the study, and filled out or answered the questions comprehensibly and completely, were included in the analysis.
Five hundred thirty two pregnant women were analyzed in line with the literature. [9,10]The other research about WaC analyzed 544 pregnant women [2] and 401 pregnant women [8] respectively.

Variables and registration
The research is an observational study, for which it is registered on the clinical trial system with NCT05131503 number in June 16, 2021.
A priori power analysis with G*Power (3.9.1.4)was done by the researcher and it indicated that a sample size of 479 would be sufficient to detect a significant small effect of WaC, assuming Odds Ratio = 1.4,alpha of 0.05 and Power of 0.90, by taking as references studies. [2,8]

Instruments
This scale was constituted by Redshaw et al, [11] which has 10 questions as a 4-point Likert scale.This scale can be used on prepartum, intrapartum and postpartum.The expressions of this scale are "I was very worried;" "I was quite worried;" "I was not quite worried;" and "I was not worried at all."The scale's total point changes between min = 10 and max = 40.As the point in the scale increases, the WaC of women decreases.Turkish validity and reliability of this scale were made by Erkal Aksoy and Gülsün Özentürk. [12]In this stage, 8 pregnant women wanted to leave the study.

Statistical analysis
Descriptive parameters were analyzed by using frequency, percent, minimum, maximum, and standard deviation statistics.Levene test was used for the equality of variances and the independent sample T test was used for comparing two groups.Test of homogeneity of variances Levene and 1-way ANOVA test were used for comparing three groups.When the significant difference was determined for three groups, if the variances were homogeneous, Tukey was used, if it was not, Games-Howell was used.The correlation among the statements was analyzed by Pearson Correlation.

Ethics approval
The ethical approval was received from Ankara City Hospital 2 Numbered Clinical Research Ethics Committee on June 16, 2021, with Decision No. E2-21-369.In addition, the pregnant women who agreed to attend the study received permission from an informed consent form.

Results
Mothers who have any antenatal class/education and work had fewer labor worries.The pregnant women who agreed with the statements of "the scenes," "the stories" and "the experiences" had more labor worries.The pregnant women, who felt stressed in their casual life had more labor worries.Besides women with dysmenorrhea had more labor worries (Table 1).There is a statistically significant difference between the points of OWLS and thoughts of pregnant women, who watched the delivery of humans and/or animals.The pregnant women, who evaluated the childbirth of humans as "riveting" had fewer labor worries than those who evaluated it as "frightening."The pregnant women who evaluated the delivery of the animal as "impressive" had fewer labor worries than those who evaluated it as "painful" (Table 2).
The outcomes of the Pearson correlation test stated that there is a statistically significant difference between working situation, antenatal education status, the labor stories which are on TV, social media, and of family/friends, feeling stressed, number of pregnancies, having dysmenorrhea, thoughts on the delivery of animal and the points of OWLS.However, there is no statistically significant difference between watching the delivery of a human and/or animal, thoughts on the childbirth of humans and the points of OWLS (Table 3).
Fifteen types of themes (Fig. 1), which consist of the responses to open-ended questions given by pregnant women were identified.The participant was abbreviated as "P" (Table 4).
Pregnant women's statements are in Table 5.

Discussion
In our study, there is no statistically significant difference between age, educational level, social support, and WaC, even though working pregnant women had less WaC.It was found that there is a statistically significant difference between being young, having a lower educational level, dissatisfaction with the partner's support and WaC in the study of Gao et al. [10] It was found that pregnant women, who has higher education levels had more WaC in the study of Qiu et al. [13] It was found that the pregnant women, who took antenatal classes/education, had lower WaC in our study.Similarly, it informed us that as accessibility to information about childbirth increases, the probabilities of WaC decrease in the study of Stoll et al. [14] It was stated that antenatal education decreases the WaC and increases the self-efficacy of mothers. [15]It was shown that the pregnant women, who have higher labor self-efficacy had lower WaC and it was emphasized that antenatal education is needed to reduce WaC and to improve the labor selfefficacy of mothers. [16]The systematic analyses of Striebich et al, [7] which persuaded 15 types of research about WaC showed that the self-efficacy of pregnant women can be strengthened, and the cesarean rates related to WaC can be decreased by taking solo or group psychoeducation sessions.Karabulut et al [17] gave antenatal education to one group of pregnant women, and they compared educated and uneducated pregnant women.A statistically significant difference in acceptance of pregnancy and the level of WaC was found among the two groups.It was stated that the adaptation of pregnancy, self-efficacy, and health literacy increased and WaC in pregnant women decreased by taking antenatal education. [18]he pregnant women, who feel stressed in their casual life had more labor anxiety in our study.Another study stated that stress, worries, depression, and insufficiency of social support were related to the fear of pregnancy. [1]In parallel with our study, a statistically significant difference was found between the self-efficacy of labor, state-trait anxiety, and WaC. [10]It was stated that low self-efficacy increases WaC. [13]P5 and P352 (theme 7) felt incompetent to push their baby, also P168 and P338 (theme 7,9) felt incompetent to breastfeed their babies.It was found that young women, who feel worried about their body changes during pregnancy and childbirth, stated more WaC. [14]In our study, P352 (theme 7) was afraid of not being able to push her baby because of the put-on weight.It was informed that the WaC affects the women, therefore they question their ability to give birth. [19][17][18][19] The results of a study that was performed with 833 women in Belgium and Holland, the women who take midwifery care had lower WaC than those who take standard obstetric care.The results emphasized that the personnel who give antenatal care as an independent model, are important to prevent the WaC. [9]he study of Hildingsson et al [20] reported that 34% of pregnant women had a known midwife during their labor, for which those had more visits for psychological consultation.In addition, they thought that the continuous care was significant, and were glad of the care.Subsequently, 29% of them informed us not have WaC.It was remarked that the severe WaC correlates with perceiving information support inadequately. [21]n our study, it was found that the pregnant women who had been affected by the birthing scenes on TV, birthing stories of their friends and family and on social media, had more labor worries.In addition, P4, P8, P11, P32, P49, P131, P136, P178, P215, P307, P427, and P492 (theme 1,6) stated that they are afraid of thoughts and approaches of other pregnant women and the stories told by the other people.Nilsson and Lundgren [19] determined that previous birth experience is the center of WaC for multipara and these pregnant women had bad experiences with taking care during childbirth.Fenwick et al [22] reported that the negative birth stories cause WaC.Stoll et al noted that WaC, attitudes to the usage of obstetric technology, getting information about pregnancy and the birthing process via social media are significantly correlated with cesarean section. [23]Qiu et al [13] reported that there is a significant correlation between using smartphone applications during pregnancy and more WaC.There is no statistically significant difference between pregnant women who watched and did not watch people/animal births in terms of WaC in Table 3 The evaluation of the correlation between OWLS points and of multi-expressions/features.our study.However, there a statistically significant difference among pregnant women who had positive and negative thoughts about animal or human birth.Parallelly to our study, it was found that pregnant women who think social media develops attitudes related to pregnancy and childbirth had more WaC. [23]lthough we did not include the pregnant women with risks in our study, 17.3% of pregnant women thought their pregnancy had any risks.There is not a significant difference between the pregnant women who thought and did not think their pregnancy has a risk in terms of WaC in our study.It was reported that pregnant women with risk in their pregnancy have more stress related to pregnancy. [24]s our study was done during the COVID-19 process, there were a few pregnant women stating worries about COVID-19 and those were P3, P70, P85, and P426 (theme 5) who were afraid of getting contaminated with COVID-19 and, of the effects of COVID-19 on their baby.In parallel with our study, it was noted that the childbirth worries of pregnant women increased because of Covid-19. [24]ne of the most important reasons for fear in pregnancy is labor pain or synthetical oxytocin.P11, P20, P27, P47, P49, P51, P59, P71, P86, P90, P106, P173, P178, P320, P339, P358, P364, P374, P423, and P480 (theme 1) stated that they are afraid of experiencing the labor pain.Moreover, P9, P46, P63, P107, P113, P128, P193, P333, P335, P337, P397, P432, P464, P474, P483, P488, P511 (theme 2) notified that they are afraid of experiencing synthetical oxytocin.It was reported that the fears of pregnant women related to having WaC. [22,25]he WaC is affected by attitudes towards hospitals and personnel and previous experiences.P84, P95, P126, P279, P318, and P518 (theme 8) stated that they are afraid of hospital and personnel's behaviors.It was found that pregnant women who have insecure feelings and attitudes to personnel's behaviors and the delivery room had more WaC. [25]WaC of pregnant women was found more have negative experiences with healthcare

Table 4
The themes related to birth fears of pregnant women.Participants expressing more than one fear are bolded.
workers. [19]It reported that a feeling of insecurity about childbirth increases WaC.It was stated that the private emotions that are not solved after previous childbirth and negative experiences affect expectations of childbirth for multiparous. [22]The result of the meta-analysis that was created from the qualitative research about the WaC reported that the lack of confidence makes it difficult to pass to motherhood and the insecure delivery room feeds WaC.This study showed that the necessity to secure care and professional support for reducing the risks and preventing the damages for maternity care is rising. [26]It was informed that the lack of positive expectation which is one of the dimensions of WaC was significantly connected with elective cesarean. [27]t was reported that the women preferred cesarean section because of WaC. [25]In our study, P262 (theme 7) stated that she wants to give birth with a cesarean section due to the fear of vaginal delivery.Also, P27 and P113 (theme 2) predicted that they wanted to give birth by taking epidural analgesia.It was reported that women who were terrified of childbirth would prefer to give birth by epidural analgesia or cesarean section. [23]t was noted that the women who stated having severe labor pain among 3189 primiparous or multiparous pregnant women, were more liable to give birth by elective cesarean section. [27]t was found that WaC increased the probability of choice of cesarean section. [23]On the contrary, there are worries about cesarean section.P7, P44, P45, P48, P52, P53, P64, P288, P294, P342, P347, P359, P395, P456, and P496 (theme 3) stated that they did not want to give birth by cesarean section and were terrified of cesarean section or anesthesia.It was noted that while the pregnant women had mid-level WaC, the pregnant women preferring cesarean section had the more intense WaC. [28]he interventions that are made in the labor process cause to increase in WaC. [26]The issues or procedures about childbirth increased WaC. [25]In our study, P6, P95, P201, P312, P365, and P391 (theme 4) indicated their fears were related to examinations or interventions.
The complications in labor or after labor have effects on WaC.In our study, it was stated that P14, P34, P103, P327, P351, and P468 (theme 10) were terrified of bleeding or dying in their labor process and after childbirth.The possibility of tearing of the perineum increased WaC. [22]lthough previous birth experience is central to the fear of childbirth for multiparous women, [22] nulliparous have no obscurity about the labor process as those who have a childbirth experience. [19]This can cause increasing WaC.In our study, P30, P56, P68, P99, P133, P195, P246, P291, P300, P313, P390, P469, and P510 (theme 11) stated that they had no idea about the labor process and that is why they were terrified.It was noted that the obscurity of the childbirth process enhances the fear of childbirth. [22]s a result, the birth process is affected by women's physiology, psychology, family, relationships, health systems and providers, and socio-cultural structures.Women expect to be able to manage the birth process, fear, and pain.1]

Conclusions
The reasons for WaC are multidimensional.The development of WaC begins in the antenatal period.Midwives and other health professionals should contact pregnant women during the antenatal period and prevent the WaC.In addition, those should pave the way for positive posts about birth on both TV and other media channels and prevent negative posts.By managing WaC, positive thoughts about vaginal birth can be spread and the rate of vaginal birth can be increased.

Limitations
There were some limitations to this study.First, more reasons can be highlighted qualitatively.However, it was not possible in the current study due to the sample size of respondents.Second, the survey only asked about childbirth worries during the antenatal period.To better understand what the reason is, longitudinal studies with questions throughout pregnancy and after childbirth should be conducted.

Figure 1 .
Figure 1.The numerical distribution of themes of birth fear.

Table 1
The comparison of OWLS points of two expressions/features.

Table 2
The comparison of OWLS points of multi-expressions/features.